The Effect of Prehabilitation, Perioperative, and Postoperative Physiotherapy on Postoperative Outcomes in Adults Undergoing Laparoscopic Surgery: A Systematic Review

Eliot McGinley; Gopala Krishna Alaparthi; Sampath Kumar Amaravadi

doi:10.12688/f1000research.179519.1

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Systematic Review

The Effect of Prehabilitation, Perioperative, and Postoperative Physiotherapy on Postoperative Outcomes in Adults Undergoing Laparoscopic Surgery: A Systematic Review

[version 1; peer review: 1 approved with reservations]

Eliot McGinley¹, Gopala Krishna Alaparthi¹, Sampath Kumar Amaravadi²

PUBLISHED 19 Apr 2026

Author details Author details

¹ Department of Health Professions, Manchester Metropolitan University,Faculty of Health and Education, Manchester, England, UK
² School of Sport Exercise and Rehabilitation Sciences,College of Life and Environmental Sciences, University of Birmingham, Birmingham, England, B15 2TT, UK

Eliot McGinley
Roles: Conceptualization, Data Curation, Methodology, Validation, Writing – Original Draft Preparation

Gopala Krishna Alaparthi
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Review & Editing

Sampath Kumar Amaravadi
Roles: Formal Analysis, Methodology, Validation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Objective

To determine the effectiveness of physiotherapy interventions for patients undergoing laparoscopic abdominal surgery on postoperative outcomes and the optimal frequency, timing, and type of intervention.

Methods

A literature search was performed in AMED, MEDLINE, CINAHL, Scopus, and Web of Science from 2009 to 2023. Randomised controlled trials (RCTs) that examined pre-operative and/or post-operative physiotherapy interventions on adults undergoing laparoscopic abdominal surgery were included. Intervention characteristics, outcome measures, and results were extracted. A tabulated summary and narrative discussion were generated to compare similarities and differences across each study.

Results

From 3811 studies identified, 9 RCTs met inclusion criteria. Preoperative incentive spirometry (IS) alone or with inspiratory muscle training (IMT) showed no postoperative pulmonary complications (PPCs) but had mixed effects on pulmonary function. Perioperative breathing interventions reduced PPCs, length of stay, and hospital costs. Trials on prehabilitation or postoperative IS found no significant PPC differences. However, prehabilitation, deep breathing exercises, IS, and mobilisation with chest physiotherapy improved pulmonary function. Mobilisation, preoperative IS, and perioperative breathing also enhanced arterial blood gas (ABG) results. Six-minute Walk test distances increased with prehabilitation, perioperative breathing, and mobilisation with chest physiotherapy. All trials had a high risk of bias, with PEDro scores of 5–8/10, indicating “fair” to “good” quality.

Conclusion

Perioperative breathing was the only intervention shown to reduce PPC rates. Prehabilitation, deep breathing exercises, IS, and mobilisation with chest physiotherapy improved pulmonary function. Larger, well-designed RCTs are needed to confirm the effectiveness of these interventions.

PROSPERO (registration ID: 529588).

Keywords

Physiotherapy, Laparoscopic surgery, Rehabilitation, Postoperative pulmonary complications.

Corresponding author: Gopala Krishna Alaparthi

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2026 McGinley E et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The author(s) is/are employees of the US Government and therefore domestic copyright protection in USA does not apply to this work. The work may be protected under the copyright laws of other jurisdictions when used in those jurisdictions.

How to cite: McGinley E, Alaparthi GK and Amaravadi SK. The Effect of Prehabilitation, Perioperative, and Postoperative Physiotherapy on Postoperative Outcomes in Adults Undergoing Laparoscopic Surgery: A Systematic Review [version 1; peer review: 1 approved with reservations]. F1000Research 2026, 15:598 (https://doi.org/10.12688/f1000research.179519.1) First published: 19 Apr 2026, 15:598 (https://doi.org/10.12688/f1000research.179519.1) Latest published: 19 Apr 2026, 15:598 (https://doi.org/10.12688/f1000research.179519.1)

Introduction

Laparoscopic surgery (LS) is a minimally invasive surgical procedure that has been used since the 1980s to reduce trauma to the abdominal wall.¹ There has been a shift in the last three decades towards using LS for certain major procedures (e.g. bowel, liver, stomach, oesophagus, and kidney resections). LS has been associated with a lower incidence of postoperative pulmonary complications (PPCs) and length of stay (LOS) compared to open surgery due to lower pain around the incision site enabling more engagement of the respiratory muscles.² PPCs can be defined as “a pulmonary abnormality that produces identifiable disease or dysfunction that is clinically significant and adversely affects the clinical course”.³ The risk reduction caused by LS is particularly evident when combined with advances in perioperative care, such as Enhanced recovery after surgery (ERAS) emphasising early mobilisation post-operatively.^1,4 There has also been conflicting evidence concerning the benefits of LS compared to open surgery.

A recent meta-analysis found a very weak advantage in favour of laparoscopic surgery over open surgery on the quality of life of patients with colorectal cancer.⁵ However, this review was limited by heterogeneity and the poor methodological rigour of the studies included indicating a need for further investigation in this area. It has been well established that general anaesthesia administered during surgery and Trendelenburg bed positioning decreases functional residual capacity (FRC), forced vital capacity (FVC), and forced expiratory volume after 1 s (FEV1) promoting atelectasis.⁶ This is even more pertinent in LS as it is associated with a comparable duration to open surgeries.⁷ Furthermore, increased intraabdominal pressure, due to the use of carbon dioxide to create a pneumoperitoneum during LS, leads to cephalad movement of the diaphragm and compression of the basal segments of the lungs contributing further to atelectasis in this patient population.^8,9 The research examining PPC prevention in this patient population is scarce and further trials are warranted to determine the effectiveness of physiotherapy as a preventative measure against PPCs.

Although PPCs are common following abdominal surgery, variation in diagnostic definitions has led to inconsistency across the literature and makes comparison between studies difficult.¹⁰ Previous work has reported incidence rates ranging from 12% to 70%,¹¹ depending on patient characteristics, surgical factors, and the criteria used to define a PPC. The use of more standardised tools, such as the Melbourne Group Score, has helped to improve consistency in some studies, although incidence remains influenced by both patient-related and procedure-related factors, including age, comorbidities, smoking status, incision location, duration of surgery, and whether the procedure is elective or emergency.^11–13

PPCs are correlated with increased morbidity due to increased LOS in hospital, readmission, and re-intubation.^13,14 This increased LOS poses a significant economic burden on the National Health Service (NHS) in the UK and healthcare systems globally as it has been associated with increased healthcare costs.¹² Therefore, physiotherapy aimed at the prevention and/or treatment of PPCs plays a key role in this healthcare dilemma.

Preoperative physiotherapy, often described as prehabilitation, aims to improve postoperative recovery by enhancing functional capacity before surgery. In the wider abdominal surgery literature, prehabilitation commonly includes exercise training and may also incorporate education, nutritional optimisation, and psychological support.¹⁵ Previous reviews in major abdominal surgery have reported mixed findings regarding its effect on PPCs, with some suggesting no significant reduction and others reporting lower pulmonary morbidity.^16,17 However, these reviews included mixed abdominal surgical populations and did not isolate patients undergoing laparoscopic procedures. It therefore remains unclear whether the same findings apply specifically to laparoscopic abdominal surgery.

Prehabilitation has become a routine practice during the preparatory phase of various surgical procedures. The evidence, although positive, is hampered by studies of low methodological quality and reporting bias due to the heterogeneity of intervention protocols.¹⁸ A small survey (N = 19) of current practice among physiotherapists in New Zealand showed that prehabilitation or preoperative assessment was rarely provided to patients.² Another survey of 57 Australian physiotherapists found that the majority provided early mobilisation in addition to “routine chest physiotherapy” on day one following upper abdominal surgery however these surveys may not reflect practice worldwide.¹⁹ This survey also identified pain, blood pressure, patient readiness, and fatigue as considerable barriers to postoperative physiotherapy intervention.

A qualitative study explored the patient’s experience of early mobilisation 2 hours after abdominal surgery.²⁰ Patients described their perceived benefits of being able to breathe more easily and a feeling of mental clarity when being able to perform everyday tasks whilst in the hospital. The study also found that being provided with individualised information before the procedure enabled them to gain some control over their recovery. Furthermore, if some patients are balancing their rehabilitation with a cancer diagnosis this makes it difficult to follow instructions given by caregivers.

The main objective of postoperative physiotherapy is to increase lung volume, optimise ventilation, facilitate airway clearance, and improve the efficiency of cough. Common interventions include deep breathing exercises, incentive spirometry, early mobilisation, airway clearance techniques, and supported coughing. However, the effectiveness of these approaches remains uncertain. Previous reviews in broader abdominal surgery populations have reported limited or inconsistent evidence for postoperative breathing interventions and incentive spirometry, while some studies have suggested possible benefits of early mobilisation on recovery outcomes such as length of stay.^21–23 Because most of this evidence is derived from mixed or predominantly open surgical populations, its relevance to laparoscopic abdominal surgery remains uncertain.

Many systematic reviews evaluating physiotherapy for abdominal surgery have combined open and laparoscopic procedures, which limits interpretation because these surgical approaches differ in tissue trauma, postoperative pain, respiratory compromise, and recovery trajectory. In addition, the available literature is characterised by methodological limitations, risk of bias, and marked heterogeneity in intervention protocols and outcome measures. As perioperative surgical care and physiotherapy practice have evolved, an updated review focused specifically on laparoscopic abdominal surgery is warranted.¹³ Therefore, the primary aim of this systematic review was to evaluate the effectiveness of preoperative, perioperative, and postoperative physiotherapy interventions on postoperative pulmonary complications and pulmonary function in adults undergoing laparoscopic abdominal surgery. A secondary aim was to examine the timing, duration, and type of intervention used across studies and to identify areas requiring further research.

Materials and methods

Search strategy and selection process

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) statement.²⁴ The review protocol was registered prospectively on PROSPERO (registration ID: 529588). Electronic searches were conducted in AMED, MEDLINE, and CINAHL via EBSCOhost, as well as Web of Science and Scopus. The search period covered January 2009 to December 2025. This broader time frame was selected following preliminary scoping, which indicated that restricting the search to the most recent 10 years yielded too few eligible studies.

Search results were exported to Microsoft Excel for deduplication and screening. Titles and abstracts were screened first, followed by full-text assessment of potentially eligible studies using a predefined screening form. Reference lists of included studies and relevant systematic reviews were also hand-searched to identify any additional eligible records. Two reviewers conducted the search, deduplication, screening, and data extraction processes. Any uncertainties regarding eligibility were discussed with the other authors. The full search strategy is presented in Appendix A, and the full-text screening template is presented in Appendix B. The study selection process is shown in the PRISMA flow diagram in Figure 1.

Figure 1. PRISMA flow diagram of study selection.

RCTs that compared prehabilitation, postoperative physiotherapy and perioperative interventions to standard care or no treatment were included. Only RCTs on adults (18 years or older) undergoing laparoscopic surgery were included in the review. The primary outcomes of the review were the rate of PPCs and parameters assessing pulmonary function, while the secondary outcomes were arterial blood gases (ABGs), LOS, six-minute walk distance (6MWD) and hospitalisation costs.

Inclusion and exclusion criteria

Studies were eligible for inclusion if they met the following criteria:

1. Participants were adults aged 18 years or older undergoing laparoscopic abdominal surgery.
2. The study design was a randomised controlled trial, including pilot or cluster randomised controlled trials.
3. The intervention consisted primarily of a physiotherapy intervention delivered in the preoperative, perioperative, or postoperative period.
4. The comparator was standard care, usual care, or no treatment.
5. The study reported at least one of the primary outcomes of interest, namely postoperative pulmonary complications or pulmonary function parameters.
6. Secondary outcomes of interest included arterial blood gases, length of stay, functional exercise capacity, and hospitalisation costs.
7. Full-text articles were available in English.

Studies were excluded if participants underwent thoracic or cardiac surgery, if the surgical approach was non-laparoscopic, or if the intervention was not principally physiotherapy based. Multimodal programmes were excluded where the specific contribution of physiotherapy could not be distinguished from other components. Reviews, case reports, and studies without accessible full text were also excluded.

Data extraction

Data extraction was performed using a structured electronic table (See Appendix). The extracted data included author, year of publication, study design, sample size, participant characteristics, surgery type, intervention and comparator details, intervention duration, follow-up time points, and reported outcomes. Primary outcomes were postoperative pulmonary complications and pulmonary function measures. Secondary outcomes were arterial blood gases, length of stay, six-minute walk distance, and hospitalisation costs. Where available, group means, standard deviations, and between-group comparisons were extracted. Data extraction was undertaken by one reviewer, with uncertainties discussed with the other authors.

Data synthesis

A narrative synthesis was undertaken because of substantial heterogeneity across studies in surgical populations, intervention type, intervention timing and duration, comparator conditions, and outcome definitions. Summary tables were used to present study characteristics and reported outcomes (see appendix). Findings were synthesised according to intervention timing, namely preoperative, perioperative, and postoperative physiotherapy interventions, and were interpreted with consideration of methodological quality and risk of bias.

Assessment of methodological quality

Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale, which is based on the Delphi list.²⁵ Each trial was scored from 0 to 10, with higher scores indicating better methodological quality. In line with previous interpretations, scores below 4 were considered poor, scores of 4 to 5 fair, scores of 6 to 8 good, and scores of 9 to 10 excellent.²⁶ The PEDro assessment was used to support interpretation of study quality rather than as a sole determinant of study value. A summary of the PEDro assessment is presented in Figure 2.

Figure 2. PEDro Scale assessment of methodological quality.

Assessment of Risk of Bias (ROB)

Risk of bias was assessed using the Cochrane Risk of Bias tool for randomised controlled trials.²⁷ The following domains were evaluated: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting, and other potential sources of bias. Each domain was rated as low, high, or unclear risk of bias. Overall judgements were then made for each study based on the ratings across domains. The traffic light plot is presented in Figure 3, and the summary plot is presented in Figure 4.

Figure 3. Risk of bias assessment traffic light plot.

Figure 4. Risk of bias summary plot.

Results

Description of included studies

A total of 3811 records were identified through database searching, with an additional two records identified through citation searching. After removal of 14 duplicates, 3795 titles and abstracts were screened. Seventy-three full-text articles were assessed for eligibility, of which nine randomised controlled trials met the inclusion criteria and were included in the review. Although the search period extended to December 2025, the included studies were published between 2010 and 2022. The study selection process is presented in Figure 1. The characteristics of the included studies are summarised in Table 1.

Table 1. Study characteristics.

First author (publication year)	Design	Intervention description	Comparator	Outcome measures	Intervention duration	Follow up
Abdelaal et al. (2017)	RCT	Preoperative Intervention • Stretching exercises • Trunk rotation • Active upper and lower extremity exercises, • Walking (10 min fast-paced) (x2/40 min sessions/week for 2 weeks) Preoperative Home Exercise Intervention • Respiratory muscle training X2/15mins/day • Walking x2/day, x4days/week. Postoperative Intervention • Deep breathing exercises & Coughing • Active upper and lower extremity exercises (x2/15min sessions/day starting day 2 post-op)	• Postoperative Therapy Only	PPC Rate PFTs (SVC, IC, MIP, MEP) 6MWT	2 weeks	• Day 1 postoperatively • Day 2 postoperatively • Day 5 postoperatively • 1 month postoperatively
Alaparthi et al. (2016)	RCT	Postoperative Intervention Patients received 1 of the following 3 interventions: 1. Diaphragmatic Breathing Exercise 2. Volume Incentive Spirometry 3. Flow Incentive Spirometry (3x5 repetitions of deep breaths) Patients in the IGs also received the following in addition to one of the above interventions: • Airway clearance techniques (huffing or coughing) • Circulation Exercises (foot and ankle pumping, hip and knee bending x10 repetitions each hour) • Thoracic expansion exercise (position patient in long sitting in bed/high sitting over the side of the bed) • Mobilisation: a) Sitting out of the bed in a chair (x2/day/x1hr) b) Walking (x3/day) c) Stair climbing was done before the patient was discharged d) from the hospital.	• No treatment	PFTs (FVC, FEV1 and PEFR)	3 days	• Day 1 postoperatively • Day 2 postoperatively
Cattano et al. (2010)	RCT	Preoperative Intervention • Incentive Spirometry (1x10 repetitions x5/day until the day of surgery).	• Incentive spirometry (x3 breaths/day)	PPC rate IC Patient Perceived Improvement, Pain Level and Patient Satisfaction Questionnaire	3 days	• Preoperatively in the day surgery unit • Postoperatively in the PACU • Postoperative day 1
Chen et al. (2022)	RCT	Perioperative Intervention • Breathing exercises based on standardized ERAS strategies (Chest expanding exercise, Tongue exercise, Deep breathing, Expectoration exercise) (x2/day for 90 days)	• Perioperative standardized ERAS strategies without any breathing exercises when in the hospital and were not given any intervention after discharge	PPCs rate Surgery-related complications 6MWT Length of stay Mortality rate Hospitalisation costs	95 days	• 1 day preoperatively • 3 days postoperatively • 30 days postoperatively • 90 days postoperatively
Duymaz et al. (2020)	RCT	Postoperative Intervention • Postural drainage (30–45-degree elevation) • Breathing exercises (deep breathing, diaphragm breathing, active breathing techniques cycle) • Coughing techniques (huffing, controlled coughing, manual-assisted coughing) • Incentive spirometry • Mobilisation (sit out of bed on day 1, 45-metre walk on day 2, 150–300 metre walks on day 3) (x2/day/x8 total)	• Mobilisation only	ABGs SpO2 PFTs 6MWT	4 days	• 1 day preoperatively • Day of discharge
Kundra et al. (2010)	RCT	Preoperative Intervention • Incentive spirometry (x15 repetitions/every 4 hrs for 7 days preoperatively)	• Postoperative incentive spirometry (x15 repetitions/every 4 hrs after operation)	PPC rate PFTs (FVC, FEV1 and PEFR) Length of stay (LOS)	7 days	• 6 hrs postoperatively • 24 hrs postoperatively • 48 hrs postoperatively • Day of discharge
Lloréns et al. (2014)	RCT	Preoperative Intervention • IMT • Incentive Spirometry (X20min for 30 consecutive days preoperatively) Postoperative physiotherapy • lung expansion exercises with the aid of the IS.	• Preoperative usual care • Postoperative lung expansion exercises with the aid of the IS.	PPC rate ABGs SpO2 PFTs (FVC, FEV1, MIP, and MEP)	30 days	• 1 hr postoperatively • 12 hrs postoperatively • Day of discharge
Pantel et al. (2017)	RCT	Postoperative Intervention • The IG did not receive an IS device or these orders. • Ambulation (x3/daily)	• Postoperative IS (x10 repetitions/every hour while awake) • Ambulation (x3/daily)	PPC rate	Until discharge	• 6 hrs postoperatively • 12 hrs postoperatively • 24 hrs postoperatively • 30 days postoperatively
Qin et al. (2021)	RCT	Perioperative Intervention • Deep breathing and coughing exercises (x5 repetitions) • Balloon-blowing exercise (4x3–4 breath holds) • Pursed lip breathing exercise (4–5 cycles per minute for 10 minutes) (Routine done x3/day for 5 days preoperatively and 4 days postoperatively)	• Standard Care	PPC Rate Pao2 LOS Hospitalisation Cost	9 days	• 1 day postoperatively • 4 days postoperatively • Day of discharge

Baseline patient characteristics

A total of 1321 patients undergoing LS participated in the 9 studies included in the review. The populations of the studies included 552 males and 719 females. One study did not report the sex of participants.²⁸ The mean age of participants ranged from 38–69.7 years. 82% of participants in one study had a body mass index (BMI) of between 30–40 kg/m2 whilst 18% of participants had a BMI of >40 kg/m2.²⁹ The mean BMI ranged from 21.45–48.6 kg/m2 in 7 studies and one study did not report on BMI.²⁸ The surgical procedures included were as follows Colorectal Surgery (n = 506), Bariatric surgery (n = 467), Cholecystectomy (n = 224), Hernia Surgery (n = 68), Appendectomy: (n = 43), Laparoscopic diagnostic (n = 8) and Splenectomy (n = 5). The baseline characteristics of patients were comparable and there were no statistically significant differences between groups apart from a study in which the BMI of the control group was significantly higher than the intervention group.³⁰ Baseline participant and surgical characteristics are presented in Table 2.

Table 2. Participant Characteristics.

Author	Population	Number of participants	Sex (males/females	Age: Mean (SD or range)	Surgery type & number
Abdelaal et al. (2017)	Adults undergoing laparoscopic upper abdominal surgery	50	22/28	IG: 55.5 (49–67) CG: 52 (47–65)	Hiatus Hernia IG: 2 CG: 2
Alaparthi et al. (2016)	Adults undergoing laparoscopic abdominal surgery.	260	157/103	DBE: 41.8 ± 13.6 FIS: 49.5 ± 16.1 VIS: 45.5 ± 15.3 CG: 46.2 ± 16.4	Cholecystectomy:140 Hernioplasty: 53 Umbilical hernia repair: 11 Appendectomy: 43 Laparoscopic diagnostic: 8 Bariatric surgery: 3 Hemicolectomy: 2
Cattano et al. (2010)	Morbidly obese adults undergoing laparoscopic bariatric surgery	41	5/36	IG: 45.26 (12.3) CG: 45.06 (12.4)	Gastric bypass: 30 Gastric sleeve: 5 Gastric lap band: 6
Chen et al. (2022)	65–80-year-old patients undergoing laparoscopic colorectal surgery	264	129/135	IG: 69.3 (10.1) CG: 70.1 (9.4)	Colon: 154 Rectal: 111
Duymaz et al. (2020)	Adults undergoing laparoscopic sleeve gastrectomy	148	20/128	IG: 38.70 ± 7.84 CG: 37.30 ± 6.48	laparoscopic sleeve gastrectomy: 148
Kundra et al. (2010)	Adults undergoing elective laparoscopic cholecystectomy	50	NR	IG: 39.9 ± 12.3 CG:46.4 ± 13.7	laparoscopic cholecystectomy: 50
Lloréns et al. (2014)	Morbidly obese adults undergoing bariatric surgery	44	23/21	IG: 43.7 ± 9.1 CG: 43.2 ± 10.9	Bariatric surgery: 44
Pantel et al. (2017)	Adults undergoing laparoscopic bariatric surgery	224	50/174	IG: 45.2 (11.2) CG: 46.0 (12.4)	Sleeve gastrectomy 118 Gastric bypass 83
Qin et al. (2021)	Adults undergoing laparoscopic colorectal resection	240	146/94	IG: 63.49 ± 12.76 CG: 62.48 ± 12.44	Colon: 129

Intervention characteristics

The studies included examined the effects of either preoperative,^28–31 postoperative^32–34 or perioperative^35,36 physiotherapy interventions. Interventions used within these studies consisted of preoperative exercise interventions, incentive spirometry, early mobilisation, postural drainage, inspiratory muscle training, breathing and coughing exercises (see Table 2). The duration of preoperative interventions ranged from 5–30 days before surgery whilst the postoperative interventions ranged from 3–4 days, however, it was unclear how long the intervention was performed in one trial.³⁴ The duration of studies with perioperative interventions ranged from 9–90 days. The controls in only one trial received no treatment.³² In three trials the control groups received standard care.^30,35,36 The controls in the remaining trials received IS in addition to standard care,³⁴ mobilisation only,³³ postoperative physiotherapy only²⁹ and postoperative incentive spirometry only.^28,31

Primary outcomes

Primary outcome findings are summarised in Table 3.

Table 3. Primary outcomes.

Outcome	Intervention group(s)	Control group	P-value
Abdelaal et al. (2017)
PPC rate
Number of participants with PPCs at Day 5 (% of the group)	7 (26.92%)	15 (62.5%)	p = 0.034
PFTs
SVC, litres, Mean ± SD	3.48 ± 0.34	3.05 ± 0.43	p ≤ .001*
IC, litres, Mean ± SD	3.11 ± 0.32	2.14 ± 0.49	p ≤ .001*
MIP, mmHg, Mean ± SD	3.24 ± 0.33	2.28 ± 0.50	p ≤ .001*
MEP, mmHg, Mean ± SD	3.51 ± 0.34	3.93 ± 0.37	p ≤ .001*
Alaparthi et al. (2016)
PFTs
FVC, litres, mean (% change from preoperative to day 2 postoperatively)	DBE: 0.28 (9.8%)	0.49 (19.5%)	P = 0.03*
	FIS: 0.37 (14.7%)		P = 0.66
	VIS: 0.28 (11.1%)		P = 0.03*
FEV1, litres, mean (% change from preoperative to day 2 postoperatively)	DBE: 0.32 (13.7%)	0.43 (21.1%)	P = 0.85
	FIS: 0.31 (15.3%)		P = 0.75
	VIS: 0.25 (12.2%)		P = 0.12
PEFR, litres/sec, mean (% change from preoperative to day 2 postoperatively)	DBE: 1.04 (17.9%)	1.25 (24.4%)	P = 1.00
	FIS: 1.17 (22.4%)		P = 1.00
	VIS: 1.02 (18.5%)		P = 1.00
Cattano et al. (2010)
PPC rate
Number of participants with PPCs	0	0	NR
Pulmonary function test(s)
Preoperative Inspiratory Capacity, cc, Mean ± SD	2155 ± 650.08	2171.43 ± 762.98	p ≤ 0.941
Postoperative Day 1 Inspiratory Capacity, cc, Mean ± SD	1458.33 ± 613.87	1557.90 ± 814.67	p ≤ 0.935
Chen et al. (2022)
PPC rate
Number of participants with PPCs (% of the group)	17 (12.88%)	43 (32.58%)	p ≤ 0.001*
Duymaz et al. (2020)
Pulmonary Function Tests
VC, Day of discharge, mL, Mean ± SD	3.90 ± 1.22	2.74 ± 0.63	p = 0.015*
ERV, Day of discharge, mL, Mean ± SD	0.79 ± 0.69	0.43 ± 0.33	p = 0.421
IRV, Day of discharge, mL, Mean ± SD	2.42 ± 0.82	1.80 ± 0.72	p = 0.141
TV, Day of discharge, mL, Mean ± SD	1.21 ± 0.67	0.54 ± 0.22	p = 0.014*
FEV1, Day of discharge, mL, Mean ± SD	2.70 ± 0.87	1.97 ± 0.84	p = 0.069
FEV1/FVC, Day of discharge, mL, Mean ± SD	88.50 ± 9.51	79.80 ± 13.44	p = 0.034*
PEF Day of discharge, litres/Sec, Mean ± SD	7.38 ± 2.41	5.17 ± 1.35	p = 0.028*
FEF25–75, Day of discharge, litres/Sec, Mean ± SD	3.62 ± 1.10	2.99 ± 1.10	p = 0.290
Kundra et al. (2010)
PPC rate
	0	0	NR
Pulmonary Function Tests
FEV1, litres (% change from baseline Mean ± SD)
Preop	2.5 ± 0.6	2.1 ± 0.5	p ≤ 0.05*
6 hrs post-op	0.9 ± 0.3	0.8 ± 0.3	p > 0.05
24 hrs post-op	1.4 ± 0.4	1.0 ± 0.3	p ≤ 0.05*
48 hrs post-op	1.6 ± 0.5	1.1 ± 0.4	p ≤ 0.05*
Discharge	1.9 ± 0.5	1.4 ± 0.4	p ≤ 0.05*
FVC, Litres (% change from baseline Mean ± SD)
Preop	2.8 ± 0.6	2.4 ± 0.5	p ≤ 0.05*
6 hrs post-op	0.9 ± 0.3	0.9 ± 0.3	p > 0.05
24 hrs post-op	1.5 ± 0.4	1.0 ± 0.3	p ≤ 0.05*
48 hrs post-op	1.7 ± 0.5	1.3 ± 0.4	p ≤ 0.05*
Discharge	2.0 ± 0.6	1.5 ± 0.4	p ≤ 0.05*
PEFR, litres/sec (Mean % change from baseline ± SD)
Preop	5.7 ± 1.6	5.2 ± 1.8	p ≤ 0.05*
6 hrs post-op	2.1 ± 1.0	2.0 ± 1.0	p > 0.05
24 hrs post-op	2.6 ± 1.0	2.5 ± 1.1	p > 0.05
48 hrs post-op	3.3 ± 1.2	2.8 ± 1.2	p ≤ 0.05*
Discharge	3.8 ± 1.1	3.8 ± 1.4	p > 0.05
Lloréns et al. (2014)
PPC Rate	0	0	NR
Pulmonary Function Tests
FVC, litres, Day 1 Preoperatively	3.49 ± 0.65	3.39 ± 0.98	p = 0.69
FEV1, litres, Day 1 Preoperatively	2.95 ± 0.59	2.78 ± 0.75	p = 0.39
MIP, cm H2O, Day 1 Preoperatively	89.9 ± 19.0	77.0 ± 21.2	p = 0.04*
MEP, cm H2O, Day 1 Preoperatively	96.39 ± 28.6	102.8 ± 37.5	p = 0.52
Pantel et al. (2017)
PPC rate (% of group)
	4 (3.6%)	8 (7.1%)	p = 0.24
Qin et al. (2021)
PPC rate (% of group)
	5 (4.17%)	14 (11.67%)	p = 0.031*

* P value <0.05 were considered statistically significant.

Postoperative pulmonary complications

Seven out of nine studies^{28–31,34–36} reported on the incidence of PPCs following the intervention period. A definition of PPCs was provided in most trials however there was a lack of definition in two trials.^28,30 The mean PPC rate across all studies was 6.91% for the intervention groups and 15.79% for the control groups. One trial examining a preoperative exercise intervention reported a PPC rate of 26.92% in the intervention group and 62.5% in the control group, and this difference was statistically significant (p = 0.034).²⁹ Three trials examining preoperative IS and IMT reported no PPCs across either group.^28,30,31 One trial examining a perioperative breathing intervention reported a rate of 12.88% in the IG and 32.58% in the CG which was statistically significant.³⁵ Another trial which examined a perioperative breathing intervention reported a PPC rate of 4.17% in the IG and 11.67% in the CG which was also statistically significant.³⁶ One trial examining a postoperative ambulation intervention to ambulation in addition to IS reported a PPC rate of 3.6% in the IG and 7.1% in the CG which was not statistically significant.³⁴

Pulmonary function parameters

Six out of nine trials reported on pulmonary function parameters.^28–33 One trial which examined a preoperative exercise therapy intervention reported highly significant differences in Slow Vital Capacity (SVC), Inspiratory Capacity (IC), Maximum Inspiratory Pressure (MIP), Maximum Expiratory Pressures (MEP) between groups preoperatively and postoperatively on days two and five.²⁹ One trial examining preoperative IS found no statistically significant differences in IC between groups preoperatively or day one postoperatively.³¹ Conversely, another trial examining preoperative IS reported significantly different values in Forced Expiratory Volume in one second (FEV1) and FVC for the IG compared to the CG preoperatively and at all time intervals postoperatively. There was a similar reduction in Peak Expiratory Flow Rate (PEFR) in both groups except at 48 hrs postoperatively when the reduction was significantly higher in the CG.²⁸ One trial examining preoperative IMT and IS reported higher values of FEV1, and FVC at 1 day preoperatively and 12 hrs postoperatively but there was no statistically significant difference between groups. There was a statistically significant difference between groups at 1 day preoperatively in MIP and MEP in favour of the IG. MIP and MEP remained higher 12 hours postoperatively in the IG however there was no statistical significance between groups.³⁰ Another trial compared one CG that received no treatment and three IGs which performed postoperative diaphragmatic breathing exercises (DBE) Flow incentive spirometry (FIS) and Volume incentive spirometry (VIS) interventions. A statistically significant difference was observed one day pre-operation and postoperative day two in FVC between the groups receiving DBE, VIS and the CG with the FVC being significantly higher in the IGs. There were no statistically significant differences in FVC between IGs or between the group receiving FIS and the CG on the one-day pre-operation and postoperative 2nd day. There was no significant difference reported in FEV1 or PEFR between any of the IGs or between the IGs and the CG or at preoperative and postoperative 2nd day.³¹ A trial examining a postoperative mobilisation and chest physiotherapy intervention reported that values for vital capacity (VC), expiratory reserve volume (ERV), inspiratory reserve volume (IRV), tidal volume (TV), FEV1, FEV1/FVC, PEFR, forced expiratory flow at 25–75% (FEF25–75) all increased in the IG however only VC, TV, FEV1/FVC, and PEFR resulted in a significant improvement compared to the CG.³³

Secondary outcomes

Secondary outcome findings are summarised in Table 4.

Table 4. Secondary outcomes.

Outcome	Intervention group(s)	Control group	P-value
Abdelaal et al. (2017)
6MWT
Pre-op, Metres, Mean ± SD	440 ± 0.47	340 ± 0.42	p ≤ 0.001*
Day 5 Post-op, Metres, Mean ± SD	395 ± 0.33	310 ± 0.50	p ≤ 0.001*
1-month Post-op, Metres, Mean ± SD	425 ± 0.40	390 ± 0.36	p ≤ 0.001*
Chen et al. (2022)
6MWT
Admission day, metres, mean (SD),	538.2 (112.7)	535.1 (123.4)	p = 0.543
1 day before surgery, metres, mean (SD)	582.4 (102.3)	538.3 (118.6)	p = 0.032*
3 days after surgery, metres mean (SD)	476.8 (112.4)	376.2 (103.5)	p ≤ 0.001*
30 days after surgery, metres, mean (SD)	536.2 (118.4)	449.4 (109.2)	p = 0.013*
90 days post-op, metres, mean (SD)	557.0 (133.5)	481.9 (102.5)	p = 0.021*
Hospitalization costs on the Day of discharge
CNY, mean (SD)	68421 (8871)	72648 (7875)	p = 0.012*
Duymaz et al. (2020)
6MWT
Metres, Mean ± SD	577.50 ± 123.85	379.70 ± 101.67	p = 0.001*
ABGs
PO2, mmHg, Mean ± SD	93.90 ± 4.35	87.10 ± 4.97	p = 0.007*
PCO2, mmHg, Mean ± SD	42.50 ± 1.64	39.80 ± 2.93	p = 0.004*
pH, Mean ± SD	7.43 ± 0.01	7.40 ± 0.01	p = 0.001*
Kundra et al. (2010)
LOS, Days, Mean ± SD	4.9 ± 0.6	5.1 ± 1.0	NR
Lloréns et al. (2014)
ABGs
Pao2/FiO2, 1 hr post-op, Mean ± SD	305.2 ± 77.6	248.8 ± 53.8	p = 0.008*
Pao2/FiO2, 12 hrs post-op, Mean ± SD	333.5 ± 59.6	289.7 ± 79.6	p = 0.044*
Qin et al. (2021)
ABGs
PaO2, pre-op, mmHg, Mean ± SD	82.15 ± 6.63	83.71 ± 5.54	p = 0.084*
PaO2, Day 1 post-op, mmHg, Mean ± SD	72.46 ± 3.68	68.73 ± 2.77	p ≤ 0.001*
PaO2, Day 4 post-op, mmHg, Mean ± SD	79.08 ± 7.12	73.23 ± 6.08	p ≤ 0.001*
Length of stay, days, median (IQR)	6 (5–7)	8 (7–9)	p = <0.001*
Hospital charges, Euro, Mean ± SD	7761 ± 1679	8212 ± 1326	p = 0.042*

* P value <0.05 were considered statistically significant

Arterial blood gases

Three trials reported on various postoperative ABG values. Duymaz et al. (2020) reported a significant increase in pressure of oxygen (PO2), pressure of carbon dioxide (PCO2) and acid-base balance (pH) scores on the day of discharge in the IG receiving postoperative chest physiotherapy and mobilisation compared to the CG receiving mobilisation only.³³ A study reported significantly higher mean oxygenation (PaO2/FiO2 ratio) values at 1 and 12 hrs postoperatively in the IG receiving preoperative IS and IMT than in the CG receiving preoperative usual care.³⁰ Similarly,³⁶ reported significantly higher mean arterial partial pressure of oxygen (PaO2) values at postoperative days 1 and 4 in the IG receiving perioperative breathing exercises compared to the CG receiving standard care.

6MWD

Three trials reported on 6MWD.²⁹ reported a significant increase in 6MWD preoperatively, day 5 and 1 month postoperatively in the IG receiving preoperative exercise therapy compared to the CG receiving postoperative therapy only.³⁵ reported a significant improvement in 6MWD 1 day preoperatively, 3 days, 30 days, and 90 days after surgery in the IG receiving perioperative breathing exercises compared to the CG receiving standard care. The CG also saw a significant decrease in their mean 6MWD compared to their baseline value.³³ reported a significant increase in 6MWD on the day of discharge in the IG receiving postoperative chest physiotherapy and mobilisation compared to the CG receiving mobilisation only.

Hospitalisation costs

Two trials reported on Hospitalisation Costs. Both³⁵ and³⁶ reported significantly lower mean hospitalisation costs in the IG compared to CG in their respective studies examining perioperative breathing interventions.

Length of stay (LOS)

Two trials examining perioperative breathing interventions reported on LOS.³⁵ reported there was a significantly lower median LOS in the IG compared to the CG. Although³⁶ also reported a lower median LOS duration there was no significant difference.

PEDro Assessment of methodological quality

Figure 2. shows a summary of the PEDro assessment. The total PEDro scores ranged from 5–8/10 achieving a rating of “fair” to “good” according to the scale. All trials fulfilled criteria for 1 (Eligibility Criteria), 2 (Random Allocation), 10 (Between-Group Analysis) and 11 (Point Estimates and variability). All trials were unable to blind participants due to the nature of the interventions used. There was also a lack of reporting regarding blinding of the therapists providing the interventions therefore both criteria 5 (Blind subjects) and 6 (Blind therapists) were not satisfied. Two trials^29,31 did not describe any methods to conceal allocation and did not satisfy criteria 3 (Concealed Allocation). In one trial most baseline data was comparable between groups however criteria 4 (Baseline Comparability) was not fulfilled as baseline BMI was higher in the CG compared to the IG.³⁰ Criteria 4 was satisfactory in all other trials. Five trials were unable to satisfy criteria 7 (Blind Assessors) as there was a lack of description of methods used to blind the outcome assessor(s).^28–32 Two trials were unable to satisfy criteria 8 (Adequate Follow-up) due to a lack of reporting on the number of participants from whom the key outcome measures were obtained.^28,33 Four trials^28,30,33,36 were unable to satisfy criteria 9 as it was specifically stated that dropouts were not included in the analysis or information regarding whether all participants were included in the final analysis was not reported.

Risk of bias assessment

Figure 3. and 4. Illustrate a summary of the ROB assessment. Random sequence generation was performed in eight studies using a computerised random number generator however the process was unclear in the other two of the studies. Allocation concealment was adequately described in seven studies with these studies opting to use numbered, opaque, sealed envelopes before group assignment. All studies were rated as high risk of bias in the blinding of participants and personnel domain as interventions would have involved either exercise or incentive spirometry making blinding of the participants impossible. Outcome assessors were blinded to allocated interventions leading to an overall low risk of detection bias. Two studies showed a low risk of selection bias however this was unclear in the remaining studies as there was insufficient information to permit other judgements. All studies were at low risk of attrition bias as most trials had no missing outcome data and any missing data balanced in numbers across groups with similar reasons for missing data. Overall studies were assessed to be at high risk of bias one or more key domains were rated as high risk of bias.

Discussion

Perioperative breathing exercises were the only type of interventions to show a significant reduction in PPCs in this review.^35,36 Additionally, participants who performed perioperative breathing exercises significantly improved postoperative ABG and 6MWT scores and experienced reduced hospitalisation costs and shorter LOS. Increased LOS is associated with increased hospitalisation costs therefore if physiotherapy interventions can reduce the LOS in this patient population this may help to mitigate the economic burden on national health services globally.¹² Although³⁶ only provided their intervention for nine days,³⁵ provided the intervention five days before surgery and ninety days following discharge which may indicate that time is a significant factor that physiotherapists and researchers should consider when designing future perioperative protocols. These findings also suggest that a combination of both preoperative and postoperative physiotherapy following discharge may be beneficial warranting further investigation in this area.³⁷ demonstrated a reduction in PPCs and LOS in patients who were provided with pre and postoperative physiotherapy as part of an enhanced recovery after surgery protocol however it is difficult to attribute these findings to physiotherapy interventions alone as this was delivered as part of a multidisciplinary protocol. There is limited data available on the impact of perioperative physiotherapy interventions alone also indicating a need for further research.

Prehabilitation may be beneficial in reducing the rate of PPCs in patients undergoing LS for hiatus hernia or colorectal problems however the reduction observed in the study examining this was not significant.²⁹ The results also indicate that prehabilitation can improve postoperative pulmonary function and 6MWT scores. Definitive conclusions are unable to be drawn from this review due to the low number of studies. However, a statistically significant reduction in the rate of PPCs has been observed in a systematic review of trials examining prehabilitation before major abdominal surgery but this level of evidence remains to be seen in the LS patient population.³⁸

Preoperative IS alone or with IMT did not reduce the risk of PPCs in patients undergoing LS.^28,30,31 There were conflicting results regarding the effect of preoperative IS on postoperative pulmonary function with one trial³¹ showing no significant difference in postoperative IC (²⁸ and another showing a significant improvement in FEV1 and FVC. Preoperative IS with IMT also significantly improved postoperative respiratory muscle function and ABGs.³⁰ MIP and MEP were used to assess respiratory muscle function in this trial. Improved MIP and MEP in this trial suggest that IMT is a potentially beneficial intervention for maintaining postoperative respiratory muscle strength. This is consistent with results from a recent RCT which also demonstrated significant improvements in respiratory muscle strength. IMT aims to improve the capacity of the diaphragm and other respiratory muscles to improve postoperative function to ensure adequate ventilation of the alveoli which may explain the significant improvement observed.³⁹ These conflicting results make it difficult to determine the impact of these interventions on postoperative pulmonary function. Heterogeneity among the intervention protocols, surgical subgroups and outcome measures used also makes comparisons difficult and may indicate reasons for differing results. Further investigation is required to make stronger conclusions regarding preoperative IS in patients undergoing LAS.

Postoperative interventions showed conflicting results. Postoperative IS appears to be an ineffective intervention as it increased the likelihood of PPCs when compared to a group performing postoperative ambulation only although the results were not statistically significant and this interpretation is limited to the results of one trial.³⁴ Furthermore, in another trial postoperative DBE, FIS and VIS all improved postoperative FVC compared to no treatment however there was no difference between these IGs, and no significant improvement was observed in postoperative FEV1 and PEFR compared to no treatment.³² These findings suggest that postoperative IS provides no benefit over DBE and in some cases may increase the risk of PPCs. This is concurrent with findings from a systematic review of patients undergoing upper abdominal surgery that found a lack of strong evidence to support the use of postoperative IS to prevent PPCs.⁴⁰ Similarly,²² reported no significant risk reduction in trials using patient-operated ventilation devices in their systematic review however most patients were undergoing open upper abdominal surgery therefore it is unclear whether this would extend to LS patients. The financial cost of the equipment to implement postoperative IS substantial,⁴¹ and considering the lack of efficacy of this intervention there may be potential to reduce the economic burden on healthcare systems should this practice be replaced with DBE although cost-effectiveness studies are warranted to make firm conclusions on this topic. In contrast, postoperative chest physiotherapy and mobilisation significantly improved ABGs, 6MWT scores and parameters associated with pulmonary function. Suggesting that this may be a viable intervention for improving postoperative function in patients undergoing LS.

Various parameters were used to assess pulmonary function across trials. Several trials used the dynamic lung volumes of FVC, FEV1 and FEV1/FVC as part of their pulmonary function test battery which have been recommended as part of the American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines for interpreting lung pathology.⁴² Although reductions in these parameters can indicate obstructive or restrictive dysfunctions following surgery there have been conflicting results regarding the correlation between pulmonary function tests and PPCs.^43–45 Further investigation regarding the correlation between pulmonary function tests and PPCs is required if these outcome measures are to be used in the LS population.

Limitations

This review has several limitations. First, the included studies were heterogeneous in terms of surgical populations, intervention type, intervention timing and duration, comparator conditions, and outcome measures. This limited direct comparison between studies and precluded meta-analysis. Second, the methodological quality of the included trials ranged from fair to good, and the overall risk of bias was high in several studies, particularly because blinding of participants and treating personnel was not feasible for many physiotherapy interventions. Third, some included trials were relatively old and may not fully reflect current perioperative practice. Finally, the review processes of screening, data extraction, PEDro scoring,^46,47 and risk of bias assessment were conducted primarily by two reviewers, which may have increased the risk of reviewer bias despite consultation with the project supervisor when uncertainties arose. These limitations mean that the findings should be interpreted as suggestive rather than definitive.

Clinical Implications

The findings of this review suggest that physiotherapy may have a meaningful role in supporting recovery after laparoscopic abdominal surgery, particularly when respiratory interventions are delivered across the perioperative period. Patients undergoing laparoscopic surgery often present with important clinical risk factors, including obesity, multiple comorbidities, reduced physical capacity, and varying levels of postoperative symptom burden.^11,15 These factors should be considered when selecting and individualising physiotherapy interventions.

From a clinical perspective, perioperative breathing exercise programmes appear promising for reducing PPCs and improving recovery outcomes in selected laparoscopic populations. Prehabilitation may also be beneficial, although the available evidence remains limited. By contrast, the evidence supporting routine postoperative incentive spirometry alone remains inconsistent. Clinicians should therefore consider the overall clinical context, patient risk profile, and available resources when deciding which interventions to prioritise. Future research should aim to identify which subgroups are most likely to benefit and should use standardised intervention reporting and outcome measures to improve translation into practice.

Conclusion

This review suggests that perioperative breathing exercise programmes may reduce postoperative pulmonary complications and improve selected recovery outcomes in adults undergoing laparoscopic abdominal surgery. Preoperative physiotherapy interventions may also offer benefit, particularly for pulmonary and functional recovery, although the evidence is less consistent. Evidence supporting routine postoperative incentive spirometry remains inconclusive. Overall, definitive conclusions cannot be drawn because of the small number of included studies, heterogeneity of interventions and outcomes, and risk of bias within the available trials. Further high-quality randomised controlled trials with larger samples, clearer intervention reporting, and standardised PPC definitions are required to determine the role of physiotherapy more precisely in this patient population.

Data availability

Underlying data

No primary datasets were generated for this systematic review. All extracted study data underlying the findings are available within the article and its tables.

Extended data

OSF: The Effect of Prehabilitation, Perioperative, and Postoperative Physiotherapy on Postoperative Outcomes in Adults Undergoing Laparoscopic Surgery: A Systematic Review. This repository contains the full search strategies, screening template, PRISMA 2020 checklist, PRISMA flow diagram, and any additional supporting materials. The OSF repository is openly available under the CC BY 4.0 licence. URL: https://doi.org/10.17605/OSF.IO/6VXHA.⁴⁸

Reporting guidelines

The study was reported in accordance with the PRISMA 2020 statement. The completed PRISMA 2020 checklist and PRISMA flow diagram for The Effect of Prehabilitation, Perioperative, and Postoperative Physiotherapy on Postoperative Outcomes in Adults Undergoing Laparoscopic Surgery: A Systematic Review are openly available on OSF at 10.17605/OSF.IO/6VXHA under the CC BY 4.0 licence.⁴⁸

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¹ Department of Health Professions, Manchester Metropolitan University,Faculty of Health and Education, Manchester, England, UK
² School of Sport Exercise and Rehabilitation Sciences,College of Life and Environmental Sciences, University of Birmingham, Birmingham, England, B15 2TT, UK

Eliot McGinley
Roles: Conceptualization, Data Curation, Methodology, Validation, Writing – Original Draft Preparation

Gopala Krishna Alaparthi
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Review & Editing

Sampath Kumar Amaravadi
Roles: Formal Analysis, Methodology, Validation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

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The author(s) declared that no grants were involved in supporting this work.

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McGinley E, Alaparthi GK and Amaravadi SK. The Effect of Prehabilitation, Perioperative, and Postoperative Physiotherapy on Postoperative Outcomes in Adults Undergoing Laparoscopic Surgery: A Systematic Review [version 1; peer review: 1 approved with reservations]. F1000Research 2026, 15:598 (https://doi.org/10.12688/f1000research.179519.1)

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Reviewer Report 13 May 2026

Ianthe Boden, University of Tasmania, Launceston, Australia

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https://doi.org/10.5256/f1000research.198044.r477080

McGinley and colleagues have conducted a systematic review focusing on the effects of perioperative physiotherapy strategies to patient and hospital outcomes after laparoscopic abdominal surgery.

Introduction – consider citing a brief overview of the

McGinley and colleagues have conducted a systematic review focusing on the effects of perioperative physiotherapy strategies to patient and hospital outcomes after laparoscopic abdominal surgery.

Introduction – consider citing a brief overview of the Melbourne Group Score (Ref 1 - Boden I, et al., 2024) to guide the reader to further information on how to use, score, and its reliability.

“Preoperative physiotherapy, often described as prehabilitation, aims to improve postoperative recovery by enhancing functional capacity before surgery.” Please consider revising this paragraph. Would preoperative breathing exercise coaching and training, also called preoperative physiotherapy, (see Boden et al BMJ 2018) be provided with the intent of enhancing functional capacity before surgery? Carefully consider how you are labelling and defining your terms. Prehabilitation systematic reviews you have cited may not include preoperative breathing exercise training, whilst physiotherapy systematic reviews tend to include both whole body exercise prehab and respiratory physiotherapy interventions.
Prehabilitation as a term may not always include preoperative physiotherapy interventions such as incentive spirometry and breathing exercises but often includes respiratory muscle training, whilst the term ‘physiotherapy interventions’ may include any type of preoperative intervention that is physical or respiratory focused, including prehab, breathing exercises, IMT etc. Calling it all prehabilitation is not how the field is labelling it. See the following as examples of perioperative physiotherapy systematic reviews and compare them to the prehab focused systematic reviews that you have cited.

(Ref 2 - Boden I, et al., 2024)
(Ref 3 - White S, et al., 2025)

Your paper will be enhanced if you specifically defining prehabilitation as including either whole-body exercise training or respiratory muscle training. Preoperative physiotherapy of breathing exercise training or incentive spirometry is not traditionally considered prehabilitation.

2. How did you define laparoscopic surgery exactly? How did you differentiate this from minimally invasive surgery?

3. How did you manage RCT’s with a mixed surgical population? For instance, studies that included laparoscopic, minimally invasive, and open procedures. What did you do if they study had a 90%:10% split of laparoscopic to open abdominal surgery? Still exclude? Did you contact the authors to see if you could access separated data or did you exclude these types of studies? If you excluded these types of studies, then please be more explicit in your inclusion criteria to state that you included studies that only included laparoscopic procedures.
4. I’m wondering why you did not include this study, (Ref 4 - Wiklund, et al., 2015). This looks like it would fit all your inclusion criteria and none of the exclusions. It would be helpful if you could provide the list of papers, you excluded and the reason for exclusions. This would improve clarity and transparency.
5. How did you define abdominal surgery? Did you include prostatectomy or inguinal hernia repairs? These could be considered abdominal surgery, depending on your definition.
6. How did you manage the inclusion of studies with multimodal physiotherapy approaches in the intervention arm e.g. exercise-based prehab combined with IMT and preoperative education followed by a postoperative intervention? It is not clear in the text. It is then not clear how to can then allocate this multimodal package to one particular ‘category’ i.e. incentive spirometry or breathing exercises or mobilisation, that you have allocated the studies to and then base your discussion on. Almost all the included studies are multimodal interventions. I’ve briefly summarized here. 4 of 9 studies are unimodal single intervention studies, whilst the other 5 are multimodal.
Abdelaal (citation #29) – 2 therapies = prehabilitation (whole body exercise) + preop IMT
Alaparthi (#32) – 2 therapies = postop breathing exercises or incentive spirometry + early mobilisation
Cattano (#31) – 1 therapy = preop incentive spirometry
Chen (#35) – 1 therapy = periop breathing exercises
Duymaz (#33) – 3 therapies = postop postural drainage + breathing exercises + incentive spirometry
Kundra (#28) – 1 therapy = preop incentive spirometry
Llorens (#30) – 2 therapies = preop IMT + incentive spirometry
Pantel (#34) – 1 therapy = postop removal of incentive spirometry
Qin (#36) – 2 therapies = periop breathing exercises + PEP
Please keep this in mind and modify your reporting of each of these papers. For instance, in the Results section in the PPC paragraph you state “One trial examining a preoperative exercise intervention reported a PPC rate of 26.92% in the intervention group and 62.5% in the control group, and this difference was statistically significant (p = 0.034) (Abdelaal et al). Consider stating that this trial examined a combination of preoperative whole-body exercise training and IMT. thinking about your interpretation of these papers. The results section would be improved with a clearer description of the different combinations of treatments being tested in the studies.
7. Please provide a full table of search terms used for Medline, as an example of your search strategy to put in the Appendix
8. Please provide a detailed description of how you defined each of your included interventions. Exactly how did you define prehabilitation, how did you define ‘perioperative physiotherapy’…?
9. Number 6 in the inclusion list is a method not an inclusion criterion.
10. How did you manage physiotherapy interventions provided by nurses or doctors? Included or excluded. I would suggest that you explain more explicitly the difference between a profession (physiotherapy or physical therapy) and a treatment (physiotherapy).
11. It’s unclear how you determined what you included in perioperative physiotherapy interventions. I know of some RCTs that have investigated yoga breathing in open abdo surg, would you have specifically excluded these if you found some in laparoscopic surgery only?
12. It is unclear how each study you have included defined a PPC in their sample. Please include the exact definition used for a PPC for each study in Table 1.
13. Table 1: Provide more detail on the time point of initiation of the breathing exercises for Chen et al. How many days before surgery did the intervention start?Cattano et al – the comparator would be best described as placebo preoperative incentive spirometry.
14. In the Intervention Characteristics paragraph: “Interventions used within these studies consisted of preoperative exercise interventions, incentive spirometry, early mobilisation, postural drainage, inspiratory muscle training, breathing and coughing exercises (see Table 2).” This should be Table 1, not 2.
15. Results – PPC “Three trials examining preoperative IS and IMT reported no PPCs across either group.” One of studies you cite #30 did not report PPCs explicitly in their results section, but listed hypoxemia incidence (also considered a PPC see Abbott et al 2018 for consensus definition statement). There was an event rate for this outcome. Definition of outcomes are vital for a high-quality systematic review. Additionally, your sentence could be interpreted that the 3 studies all provide IS and IMT, rather it should be “IMT and/or IS”, as there were 2 that delivered IS alone and one that provided it in combination with IMT.
16. “One trial examining a postoperative ambulation intervention to ambulation in addition to IS reported a PPC rate of 3.6% in the IG and 7.1% in the CG which was not statistically significant.” You need to be carefully considered how you interpret the findings of a non-inferiority trial, as the intervention group was the removal of IS and the control group was usual care. The intent of a non-inferiority study is NOT showing a statistically significant result – to find if the two treatment arms are not grossly different.
17. Discussion – for the study that provided two types of prehabilitation (whole-body exercise and IMT) you claim that ‘prehabilitation’ may improve outcomes. Do you think that this effect would come from the IMT alone, whole-body exercise alone, or a combination of both?
18. Please downgrade your summary of outcomes in your discussion. There are not enough studies to make conclusions about outcomes only suggestions. Replace ‘did not reduce’ to ‘may reduce’. Your discussion terminology is too declarative for a review where you couldn’t conduct a meta-analysis.
19. Citation #30; you have not included a journal for this paper in the references. Please check that you have represented the included citations correctly.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Yes
Are the conclusions drawn adequately supported by the results presented in the review?

Partly
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

No

References

1. Boden I, Hackett C: Clinimetrics: The Melbourne Group Scale. Journal of Physiotherapy. 2024; 70 (4). Publisher Full Text
2. Boden I: Physiotherapy management of major abdominal surgery. Journal of Physiotherapy. 2024; 70 (3): 170-180 Publisher Full Text
3. White S, Mani S, Martin R, Reeve J, et al.: Interventions Provided by Physiotherapists to Prevent Complications After Major Gastrointestinal Cancer Surgery: A Systematic Review and Meta-Analysis. Cancers. 2025; 17 (4). Publisher Full Text
4. Wiklund M, Sundqvist E, Fagevik Olsén M: Physical Activity in the Immediate Postoperative Phase in Patients Undergoing Roux-en-Y Gastric Bypass—a Randomized Controlled Trial. Obesity Surgery. 2015; 25 (12): 2245-2250 Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Physiotherapy and the prevention of postoperative pulmonary complications after abdominal surgery. Health economics. Prehabilitation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Ianthe Boden, University of Tasmania, Launceston, Australia

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13 May 2026 | for Version 1

Ianthe Boden, University of Tasmania, Launceston, Australia

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Approved With Reservations

McGinley and colleagues have conducted a systematic review focusing on the effects of perioperative physiotherapy strategies to patient and hospital outcomes after laparoscopic abdominal surgery.

Introduction – consider citing a brief overview of the Melbourne Group Score (Ref 1 - Boden I, et al., 2024) to guide the reader to further information on how to use, score, and its reliability.

“Preoperative physiotherapy, often described as prehabilitation, aims to improve postoperative recovery by enhancing functional capacity before surgery.” Please consider revising this paragraph. Would preoperative breathing exercise coaching and training, also called preoperative physiotherapy, (see Boden et al BMJ 2018) be provided with the intent of enhancing functional capacity before surgery? Carefully consider how you are labelling and defining your terms. Prehabilitation systematic reviews you have cited may not include preoperative breathing exercise training, whilst physiotherapy systematic reviews tend to include both whole body exercise prehab and respiratory physiotherapy interventions.
Prehabilitation as a term may not always include preoperative physiotherapy interventions such as incentive spirometry and breathing exercises but often includes respiratory muscle training, whilst the term ‘physiotherapy interventions’ may include any type of preoperative intervention that is physical or respiratory focused, including prehab, breathing exercises, IMT etc. Calling it all prehabilitation is not how the field is labelling it. See the following as examples of perioperative physiotherapy systematic reviews and compare them to the prehab focused systematic reviews that you have cited.

(Ref 2 - Boden I, et al., 2024)
(Ref 3 - White S, et al., 2025)

Your paper will be enhanced if you specifically defining prehabilitation as including either whole-body exercise training or respiratory muscle training. Preoperative physiotherapy of breathing exercise training or incentive spirometry is not traditionally considered prehabilitation.

2. How did you define laparoscopic surgery exactly? How did you differentiate this from minimally invasive surgery?

3. How did you manage RCT’s with a mixed surgical population? For instance, studies that included laparoscopic, minimally invasive, and open procedures. What did you do if they study had a 90%:10% split of laparoscopic to open abdominal surgery? Still exclude? Did you contact the authors to see if you could access separated data or did you exclude these types of studies? If you excluded these types of studies, then please be more explicit in your inclusion criteria to state that you included studies that only included laparoscopic procedures.
4. I’m wondering why you did not include this study, (Ref 4 - Wiklund, et al., 2015). This looks like it would fit all your inclusion criteria and none of the exclusions. It would be helpful if you could provide the list of papers, you excluded and the reason for exclusions. This would improve clarity and transparency.
5. How did you define abdominal surgery? Did you include prostatectomy or inguinal hernia repairs? These could be considered abdominal surgery, depending on your definition.
6. How did you manage the inclusion of studies with multimodal physiotherapy approaches in the intervention arm e.g. exercise-based prehab combined with IMT and preoperative education followed by a postoperative intervention? It is not clear in the text. It is then not clear how to can then allocate this multimodal package to one particular ‘category’ i.e. incentive spirometry or breathing exercises or mobilisation, that you have allocated the studies to and then base your discussion on. Almost all the included studies are multimodal interventions. I’ve briefly summarized here. 4 of 9 studies are unimodal single intervention studies, whilst the other 5 are multimodal.
Abdelaal (citation #29) – 2 therapies = prehabilitation (whole body exercise) + preop IMT
Alaparthi (#32) – 2 therapies = postop breathing exercises or incentive spirometry + early mobilisation
Cattano (#31) – 1 therapy = preop incentive spirometry
Chen (#35) – 1 therapy = periop breathing exercises
Duymaz (#33) – 3 therapies = postop postural drainage + breathing exercises + incentive spirometry
Kundra (#28) – 1 therapy = preop incentive spirometry
Llorens (#30) – 2 therapies = preop IMT + incentive spirometry
Pantel (#34) – 1 therapy = postop removal of incentive spirometry
Qin (#36) – 2 therapies = periop breathing exercises + PEP
Please keep this in mind and modify your reporting of each of these papers. For instance, in the Results section in the PPC paragraph you state “One trial examining a preoperative exercise intervention reported a PPC rate of 26.92% in the intervention group and 62.5% in the control group, and this difference was statistically significant (p = 0.034) (Abdelaal et al). Consider stating that this trial examined a combination of preoperative whole-body exercise training and IMT. thinking about your interpretation of these papers. The results section would be improved with a clearer description of the different combinations of treatments being tested in the studies.
7. Please provide a full table of search terms used for Medline, as an example of your search strategy to put in the Appendix
8. Please provide a detailed description of how you defined each of your included interventions. Exactly how did you define prehabilitation, how did you define ‘perioperative physiotherapy’…?
9. Number 6 in the inclusion list is a method not an inclusion criterion.
10. How did you manage physiotherapy interventions provided by nurses or doctors? Included or excluded. I would suggest that you explain more explicitly the difference between a profession (physiotherapy or physical therapy) and a treatment (physiotherapy).
11. It’s unclear how you determined what you included in perioperative physiotherapy interventions. I know of some RCTs that have investigated yoga breathing in open abdo surg, would you have specifically excluded these if you found some in laparoscopic surgery only?
12. It is unclear how each study you have included defined a PPC in their sample. Please include the exact definition used for a PPC for each study in Table 1.
13. Table 1: Provide more detail on the time point of initiation of the breathing exercises for Chen et al. How many days before surgery did the intervention start?Cattano et al – the comparator would be best described as placebo preoperative incentive spirometry.
14. In the Intervention Characteristics paragraph: “Interventions used within these studies consisted of preoperative exercise interventions, incentive spirometry, early mobilisation, postural drainage, inspiratory muscle training, breathing and coughing exercises (see Table 2).” This should be Table 1, not 2.
15. Results – PPC “Three trials examining preoperative IS and IMT reported no PPCs across either group.” One of studies you cite #30 did not report PPCs explicitly in their results section, but listed hypoxemia incidence (also considered a PPC see Abbott et al 2018 for consensus definition statement). There was an event rate for this outcome. Definition of outcomes are vital for a high-quality systematic review. Additionally, your sentence could be interpreted that the 3 studies all provide IS and IMT, rather it should be “IMT and/or IS”, as there were 2 that delivered IS alone and one that provided it in combination with IMT.
16. “One trial examining a postoperative ambulation intervention to ambulation in addition to IS reported a PPC rate of 3.6% in the IG and 7.1% in the CG which was not statistically significant.” You need to be carefully considered how you interpret the findings of a non-inferiority trial, as the intervention group was the removal of IS and the control group was usual care. The intent of a non-inferiority study is NOT showing a statistically significant result – to find if the two treatment arms are not grossly different.
17. Discussion – for the study that provided two types of prehabilitation (whole-body exercise and IMT) you claim that ‘prehabilitation’ may improve outcomes. Do you think that this effect would come from the IMT alone, whole-body exercise alone, or a combination of both?
18. Please downgrade your summary of outcomes in your discussion. There are not enough studies to make conclusions about outcomes only suggestions. Replace ‘did not reduce’ to ‘may reduce’. Your discussion terminology is too declarative for a review where you couldn’t conduct a meta-analysis.
19. Citation #30; you have not included a journal for this paper in the references. Please check that you have represented the included citations correctly.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Yes
Are the conclusions drawn adequately supported by the results presented in the review?

Partly
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

No

References

1. Boden I, Hackett C: Clinimetrics: The Melbourne Group Scale. Journal of Physiotherapy. 2024; 70 (4). Publisher Full Text
2. Boden I: Physiotherapy management of major abdominal surgery. Journal of Physiotherapy. 2024; 70 (3): 170-180 Publisher Full Text
3. White S, Mani S, Martin R, Reeve J, et al.: Interventions Provided by Physiotherapists to Prevent Complications After Major Gastrointestinal Cancer Surgery: A Systematic Review and Meta-Analysis. Cancers. 2025; 17 (4). Publisher Full Text
4. Wiklund M, Sundqvist E, Fagevik Olsén M: Physical Activity in the Immediate Postoperative Phase in Patients Undergoing Roux-en-Y Gastric Bypass—a Randomized Controlled Trial. Obesity Surgery. 2015; 25 (12): 2245-2250 Publisher Full Text

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Physiotherapy and the prevention of postoperative pulmonary complications after abdominal surgery. Health economics. Prehabilitation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Respond to this report

Responses (0)

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[14] 14. Lusquinhos J, Tavares M, Abelha F, et al.: Postoperative pulmonary complications and perioperative strategies: a systematic review. Cureus. 2023; 15(5).

[15] 15. Lundberg M, Archer K, Larsson C, et al.: Prehabilitation: the emperor’s new clothes or a new arena for physical therapists? Phys. Ther. 2019; 99(2): 127–130.

[16] 16. Hughes M, Hackney R, Lamb P, et al.: Prehabilitation before major abdominal surgery: a systematic review and meta-analysis. World J. Surg. 2019; 43: 1661–1668.

[17] 17. Lyons N, Bernardi K, Olavarria O, et al.: Prehabilitation among patients undergoing non-bariatric abdominal surgery: a systematic review. J. Am. Coll. Surg. 2020; 231(4): 480–489.

[18] 18. Kamarajah S, Bundred J, Weblin J, et al.: Critical appraisal on the impact of preoperative rehabilitation and outcomes after major abdominal and cardiothoracic surgery: a systematic review and meta-analysis. Surgery. 2020; 167(3): 540–549. Publisher Full Text

[19] 19. Patman S, Bartley A, Ferraz A, et al.: Physiotherapy in upper abdominal surgery–what is current practice in Australia? Archives of physiotherapy. 2017; 7: 1–1. Publisher Full Text

[20] 20. Svensson-Raskh A, Schandl A, Holdar U, et al.: “I have everything to win and nothing to lose”: patient experiences of mobilization out of bed immediately after abdominal surgery. Phys. Ther. 2020; 100(12): 2079–2089. PubMed Abstract | Publisher Full Text | Free Full Text

[21] 21. Castelino T, Fiore J Jr, Niculiseanu P, et al.: The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: a systematic review. Surgery. 2016; 159(4): 991–1003. Publisher Full Text

[22] 22. Kokotovic D, Berkfors A, Gögenur I, et al.: The effect of postoperative respiratory and mobilization interventions on postoperative complications following abdominal surgery: a systematic review and meta-analysis. Eur. J. Trauma Emerg. Surg. 2021; 47: 975–990. PubMed Abstract | Publisher Full Text

[23] 23. Sullivan K, Churchill I, Hylton D, et al.: Use of incentive spirometry in adults following cardiac, thoracic, and upper abdominal surgery to prevent post-operative pulmonary complications: a systematic review and meta-analysis. Respiration. 2021; 100(11): 1114–1127.

[24] 24. Page M, McKenzie J, Bossuyt P, et al.: The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021.

[25] 25. Verhagen A, De Vet H, De Bie R, et al.: The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. J. Clin. Epidemiol. 1998; 51(12): 1235–1241. Publisher Full Text

[26] 26. Cashin A, McAuley J: Clinimetrics: physiotherapy evidence database (PEDro) scale. J. Physiother. 2020; 66(1): 59.

[27] 27. Higgins J, Altman D, Gøtzsche P, et al.: The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011; 343: d5928. Publisher Full Text

[28] 28. Kundra P, Vitheeswaran M, Nagappa M, et al.: Effect of preoperative and postoperative incentive spirometry on lung functions after laparoscopic cholecystectomy. Surg. Laparosc. Endosc. Percutan. Tech. 2010; 20(3): 170–172. PubMed Abstract | Publisher Full Text

[29] 29. Abdelaal G, Eldahdouh S, Abdelsamie M, et al.: Effect of preoperative physical and respiratory therapy on postoperative pulmonary functions and complications after laparoscopic upper abdominal surgery in obese patients. Egypt J Chest Dis Tuberc. 2017; 66(4): 735–738. Publisher Full Text

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[33] 33. Duymaz T, Karabay O, Ural I: The effect of chest physiotherapy after bariatric surgery on pulmonary functions, functional capacity, and quality of life. Obes. Surg. 2020; 30: 189–194. Publisher Full Text

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[37] 37. Wing C, Kwan F, Yan T, et al.: Role of physiotherapy in enhanced recovery after surgery for colorectal surgery–Hong Kong experiences. Clin Nutr ESPEN. 2019; 31: 116. Publisher Full Text

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[44] 44. Oh T, Park I, Ji E, et al.: Value of preoperative spirometry test in predicting postoperative pulmonary complications in high-risk patients after laparoscopic abdominal surgery. PLoS One. 2018; 13(12): e0209347. Publisher Full Text

[45] 45. Park H, min Kim S, Kim H, et al.: The value of preoperative spirometry testing for predicting postoperative risk in upper abdominal and thoracic surgery assessed using big-data analysis. J. Thorac. Dis. 2020; 12(8): 4157.

[46] 46. Albanese E, Bütikofer L, Armijo-Olivo S, et al.: Construct validity of the Physiotherapy Evidence Database (PEDro) quality scale for randomized trials: Item response theory and factor analyses. Res. Synth. Methods. 2020; 11(2): 227–236. PubMed Abstract | Publisher Full Text | Free Full Text

[47] 47. De Morton N: The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust. J. Physiother. 2009; 55(2): 129–133.

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The Effect of Prehabilitation, Perioperative, and Postoperative Physiotherapy on Postoperative Outcomes in Adults Undergoing Laparoscopic Surgery: A Systematic Review

Abstract

Objective

Methods

Results

Conclusion

Keywords

Introduction

Materials and methods

Search strategy and selection process

Figure 1. PRISMA flow diagram of study selection.

Inclusion and exclusion criteria

Data extraction

Data synthesis

Assessment of methodological quality

Figure 2. PEDro Scale assessment of methodological quality.

Assessment of Risk of Bias (ROB)

Figure 3. Risk of bias assessment traffic light plot.

Figure 4. Risk of bias summary plot.

Results

Description of included studies

Table 1. Study characteristics.

Baseline patient characteristics

Table 2. Participant Characteristics.

Intervention characteristics

Primary outcomes

Table 3. Primary outcomes.

Secondary outcomes

Table 4. Secondary outcomes.

Risk of bias assessment

Discussion

Limitations

Clinical Implications

Conclusion

Data availability

Underlying data

Extended data

Reporting guidelines

Reference List

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